Whats new in Respiratory Sepsis

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Whats new in Respiratory Sepsis?
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Voltaire
Patients mostly get better by themselves.
Its the job of the physician to entertain them
on the way
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Need to entertain

• Acute exacerbations of COPD
• Pneumonia
• Bronchiectasis
• (not pleural sepsis or opportunistic
  infections)

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Need to distinguish

• Type
• URTIs
• AECOPD
• Pneumonia
• bronchiectasis
• Non-severe from severe
• Community from hospital acquired

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Pulmonary infections

• Very common
• Pneumonia alone gt60 000 deaths in UK each
  year
• Remain a major cause of death despite antibiotics
• Unprecedented increase in antibiotic resistance

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What can we do?

• Discover more antibiotics?
• 70 of antibiotics fed to animals
• Judicious use of antibiotics

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Acute exacerbation of COPD(AECOPD)
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AECOPD
Neutrophil inflammation

• Pneumococcus
• Haemophilus
• Moraxella

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Treatment of AECOPD

• Not Pneumonia
• Which antibiotic?
• Amoxicillin
• Doxycycline
• 2nd line - Co-amoxyclav
• or erythro / clarithromcyin
• not ciprofloxicin alone
• Oral cephalosporins not great

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New drugs

• Moxifloxicin
• Once daily
• Oral only
• 3rd generation quinolone with activity against
  Pneumococcus
• Erdosteine
• Mucolytic
• Anti-inflammatory properties
• Used as 10 day course during AECOPD

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Pneumonia
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Distinguish

• URTIs, AECOPD, pneumonia and bronchiectasis
• Non-severe from severe
• Community vs. hospital acquired

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Community Acquired Pneumonia

• Who can be treated at home?
• Who should be hospitalised?
• How aggressive?
• Ordinary ward or ITU?
• Are there useful markers of severity to allow
  appropriate triage?

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Assessing severity

• US
• 20 parameter assessment
• Pneumonia severity index (PSI score)
• 18 reduction in admission rate for non-severe
  CAP
• UK
• 5 or 4 score parameters (CURB-65)
• Useful to predict 30 day mortality

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CURB 65

• C onfusion MMT 8
• U rea gt 7
• R espiratory rate gt30
• B lood pressure diastolic BP 60
• or systolic BP lt90
• 65 age or older
• Where Urea result not available
• CRB-65

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CRB-65
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Investigations
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Value of sputum culture is poor

• non-severe pneumonia
• no co-morbid disease
• received prior antibiotics
• Dont culture unless
• severe infection
• previous multiple antibiotics
• will usefully help guide management

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Investigations urinary antigen

• Legionella urinary antigen
• Pneumococcal urinary antigen
• more sensitive than sputum and blood culture
• no evidence yet for benefit in final outcome

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CRP

• Better than WCC to detect CAP in febrile patient
• Not related to severity
• Useful to distinguish CAP from AECOPD
• lt 50 CAP unlikely
• gt 100 CAP likely (AECOPD unlikely)

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Differential diagnosis

• Opportunistic infection (TB, MAI, PCP)
• Cancer
• Foreign body
• COP (cryptogenic organising pneumonia)
• Connective tissue diseases
• Eosinophilic pneumonia
• ABPA

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Differential diagnosis
Right upper lobe tumour
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If partial lung collapse -consider obstructive
lesion
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Bronchoscopy
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Voltaire
Yes, but can you do anything useful?
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What about recurrent infections?
Diagnose, CRB65 and Rx

Not Amoxicillin 250mg tablets in adults
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Bronchiectasis
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Definition

• Chronic nerotizing infection of the bronchi and
  bronchioles
• Leads to abnormal dilation of airways

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Clinical features

• Chronic cough
• Copious foul-smelling purulent sputum
• SOB
• Wheeze

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Bronchiectasis

• Dilated bronchi

Fibrosis
Sacules
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Bronchiectasis

• Microscopic appearance
• Loss of cilia
• Intense inflammatory exudate
• Fibrosis

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Pathogenesis - infection

• Any severe bacterial pneumonia
• Tuberculosis
• Childhood infection
• whooping cough
• measles
• adenovirus

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Pathogenesis - host defence defects

• Immune defects
• Hypogammaglobulinaemia
• Hyperimmune states
• ABPA
• Mucociliary clearance defects
• cystic fibrosis

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Pathogenesis - miscellaneous

• Inflammatory disease
• rheumatoid arthritis
• Yellow nail syndrome
• Absence of bronchial cartilage

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Symptoms

• Cough
• intermittent or continuous
• dry or productive
• sputum (clear or purulent)
• SOB
• Exacerbations
• worsening SOB/cough/sputum colour and volume
• haemoptysis

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Signs

• May be very little
• Crackles
• coarse
• localised or widespread
• Wheeze
• Clubbing
• Pulmonary hypertension /
• cor pulmonale

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Investigations

• Sputum culture
• Imaging
• Spirometry
• Consider specific diseases
• CF
• Hypogammaglobulinaemia
• ABPA

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Bronchography
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Sacular bronchiectasis
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Treatment

• Physiotherapy
• postural drainage
• Active cycle of breathing technique (ACBT)
• Treat airflow obstruction
• bronchodilators
• inhaled corticosteroids
• Antibiotics

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What organism?

• Strep. Pneumoniae
• Haemophilus influenzae
• Staph. Aureus
• Pseudomonas spp.
• Burkholderia capacia

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Microbiology is crucial

• Do they have Pseudomonas?

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• No
• Use simple narrow spectrum 1st line ABx
• History of previous antibiotics important
• Avoid too many repeats of the same
• High dose and longer duration than acute
  bronchitis

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• Yes
• Use oral quinolone e.g. ciprofloxicin
• Other oral classes will not be effective
• High dose and long duration e.g. cipro
• 500 mg bd 7 days minimum
• 750 mg bd for 10-14 days

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Need regular sputum culture

• Bronchiectasis ?Pseudomonas.
• Please do sensitivities
• Dr V. Hopeful

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Antibiotics

• Oral
• Intermittent for exacerbations
• Cover the Winter
• Long term
• One continuously or Ring the changes?
• Nebulised antibiotics
• Colomycin or Gentamicin

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Antibiotics

• Intravenous
• Hospital
• Home (PICC lines)

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Nebulised Antibiotics

• Colomycin (or gentamicin)
• Need correct nebuliser
• Salbutamol before
• May produce very dramatic clinical response

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Pseudomonas eradication

• Extrapolated from CF data
• 2 weeks iv dual therapy in hospital
• 2 weeks po ciprofoxicin 750 bd
• 4 weeks neb colomycin 2 MU bd
• Four month home regimen
• Neb. Colomycin
• and ciprofloxicin 750 mg bd

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Key messages

• AECOPD
• narrow spectrum antibiotics
• Pneumonia
• Consider differential diagnosis
• Amoxicillin 500 mg dose or above
• Dont prescribe ciprofloxicin alone
• Bronchiectasis
• Sputum culture helpful
• Treat early with high doses and longer duration
• Is there Pseudomonas?